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i have been told but a residency director that his concern is the professional desires of his trainees, rather than population health needs. perhaps the most important policy reform which could make to reinvigorate primary-care

would be to address the pay disparity with specialists. this could be done by raising primary care pay, or decrease in that of specialists. i feel it is the disparity that is the driving force in this workforce problem we are facing today. the american association of medical colleges has declared that education and training cannot overcome intense market incentives. a vocal, point for payment reform has been mentioned. aha a committee is a secretive group of doctors that wields tremendous influence over medicare reimbursement rates. the cms and adopts nearly all of their recommendations. at a minimum, the public deserves transparency. but yet, we should establish rates of thing that is not favoring narrow specialties. the federal government and ama are colluding to bring an end to the primary care physician

work force in the united states. in summary, it is clear that health insurance provides better health outcomes, including a decrease risk for death. despite this, we will leave 30 million uninsured. i have worked for over a decade in medical education as a student, resident, fellow, and a faculty member and program later. it is my conviction that public responsive training should meet the health care needs of our population, and rather than the staffing needs of hospitals or the lifestyle preferences of young doctors. >> my understanding is that senator franken has to leave, and you wanted to ask a brief question. is that correct? >> thank you, mr. chairman. i guess, yes. that would be a yes. and you are talking about the compensation.

you probably heard my comment earlier about the return on investment, in terms of loan forgiveness for primary-care physicians. what would that look like? in other words, i know we do some loan forgiveness. we do it for people serving in underserved communities. what would that look like? how could you compute that in terms of the value that you would get back over the course of a physician's career? if you said, if you go into -- if you are a gp, $100,000 off of your loan. have studies been done to do that?

>> to my knowledge, there is no systematic review of that specific question. i know in my home state of idaho, which is a neighbor to wyoming and exceptionally rural, we have programs to help offset debt related to medical education. those have been somewhat successful. i would defer to the panelists to my left, dr. reinhardt. >> as a medical economist, may i ask you that? >> microphone, please. >> if you have more primary- care physicians, that will improve access. the institute of benison studies show that will produce better health and life years. we economists can convert that into a quality-adjusted light years. usually, the assumption of value is imputed to that. i know david cutler and others

use $100,000, just to put a value on it. by having more physicians in that field, providing better access, how many qualities have you produced -- like years saved or better quality of life. the return is fairly high. >> i would love for that to be done. >> i will ask a student. >> i just have to minutes left, and then i will go. >> but that is all you have left any doubt. >> that is what i meant. i was making the same point. i would like those three seconds back. to senator murphy's have a question or comment about the status -- i think your status is partly determined by your salary.

i think the relative value board you were talking about -- i cannot remember the name. in other countries, he what is the compensation like, in terms of general practitioner to specialists? is it different? is it lower? i mean, is the ratio higher from the gp to specialists in other countries, versus here? >> specialists do earn more, i know, for instance, in germany, but not as much as they do here. gp's generally do have lower pay, and occasionally protest about that. it happens over there. but i do not think the ratio is quite as large. >> the have lower health-care

costs and as good outcomes, if not better. >> about half. >> in health care costs. i just want to do this. senator murphy again brought this up. accountable care organizations, which we have a lot of in our state, and health care homes -- medical homes -- would elevate the role of a general practitioner in that model, in the sense that they would be sort of organizing this team that does the care? does anybody have an opinion on that? >> specifically, unless a fee- for-service payment mechanism is a change -- there is a

proposal to do that in these new medical home models, to move to a capitated system. there is a chance that would move the needle. i would caution -- i know this research fairly well. there is limited evidence that patient-centered medical homes are going to reduce costs. i think that intervention, while worthy, and we are working on it at the state level and with the va, is still, in my view, is still experimental. >> thank you. one last thing. i really thought it was really off base for the ranking member to use your willingness to come here to testify to moan about his weekly commute. [laughter] >> let me introduce a man who has already spoken for -- reintroduce him. and that is dr. reinhardt. he is the james madison professor of political economy

at princeton university, and contributing writer to "the new york times" economix blog. thank you for being with us. >> i am very honored by it. i should have added that i was delivered by a midwife, and of course my mother. i once told that to a member of the american medical association. he said, it shows. i am not sure what he meant. i divided my written statement into three parts. is our medical capability efficiently used? the answer is no. the second is, what public policy levers does congress have, given that we want more

primary-care physicians, to move them into that field, and also to practice where they are needed? the third is, to what extent can financial incentives be used, which you have already answered him and talked about. the traditional model of workforce forecasting has been to focus on physician population ratios, as if all the other people who work in the primary care team did not matter. my whole career has been to say we should use non-physician workers far more imaginatively, he and let them practice independently, in full competition with physicians. that was very controversial many years ago. less so now. many states actually already allow that. the congress has made a very large role in innovating in this field, by funding the

training of nurse practitioners and physician's assistants, and also creating community health centers and other such things where they can very, very effectively be used. there are issues of licensing. congress could address them. usually, licensing is professional licensing with appeal to patients' safety and quality. usually, the violins, when i hear that. i think it is mainly over economic turf and always has been. i remember the fight over whether optometrist's could dilate pupils. i think it was settled years ago. those were the issues. it is almost like an insurgent war that has to be thought. i think the congress should simply make sure that licensing is driven by clinical and economic considerations, patient quality, and not by economic turf.

there is the issue of, scopes of practice, which states dominate. there are huge variations in a. i believe there should be -- i agree with the nursing profession. there should be a standard s.o.p. for the nation which should allow the nurses to practice independently. physician assistants, by their nature, are supervised by physicians. on the second question of how can you drive physicians to the extent you definitely need them in these teams, into primary care, there is the issue of prestige, as senator murphy mentioned. my view on that is, and the numerous primary-care medical homes -- is it is not just money. it is also power.

they are not gatekeepers, but they are traffic cops. i think in those settings, their prestige would rise. i told that to our daughter, who is an internist, yesterday. i said, i would be very excited to be a primary care physician now. the entrepreneurial opportunities are limitless there, much less in other specialties. on the final point, compensation is clearly an issue. mr. chairman, you mentioned that over the lifetime, a specialist $2 million to $3 million more. that is such a small sum when you think of the goldman managing director. if the or the annual bonus, he

would be offended by it. it probably would do something. it signals value to people. the debt forgiveness -- i think that should definitely be done. it is sort of like the national health service corps. i would say for every year you practice -- you could say, if you go into a specialized primary care, he will forgive you $80,000 upfront. for every year you specialize in the location we would like you to go, we will forgive you $20,000. to have that incentive out there. finally, i thought -- and i think we are allowing private equity managers to take what is really just earned income, a commission, and get capital gains taxes on it, carry interest -- why don't we honor primary-care physicians in america as we honor private equity managers, and give them the same rate, if they go to rural areas?

the precedent exists. congress says, carried interest -- we want to encourage capital formation. that is capital. physicians are human capital, and we want to encourage them. thank you. >> thank you very much. last but very much not least is dr. claudia fagan, the chief medical officer for the hospital of cook county, chicago. she was previously the associate chief medical officer for the is ambulatory community health network, and interim chief medical officer of the bureau of health services. she received her undergraduate degree from fisk university, and her medical degree from the university of illinois college of medicine. thanks so much for being with us.

>> thank you, senator sanders and other distinguished senators, for affording me this opportunity to address inadequate access to primary care in the united states. as the chief medical officer of cook county hospital, a confront on a daily basis our country's failure to provide universal access to health care, the right to which i believe everyone is entitled. every day, people without a physician lined up across the street to be seen in our clinic. hundreds of people a week. tens of thousand a year. they stand out in the week, hours of the morning, hoping to be one of the 120 people we will be seeing that day. even better, hoping to be one of the 12 patients who will be assigned a primary care physician and given an appointment, so they will not have to come back. there will be one of the lucky ones to be given a position of their own.

our current influenza epidemic highlights the patchwork. too few people have access to the primary care provider. their primary health care provider could have educated them about influenza and the need for influenza vaccine, especially for those in contact with those who populations. their primary care provider could have given them that a vaccine. instead, we are witnessing tens of thousands of people in our emergency rooms. at the peak, our emergency room was seeing 450 people a day, while hospitals around the country who close their doors and went on bypass. at cook county, we never go on bypass. we never close our doors. we created a system to compensate physicians for their cognitive effort in the care of patients. it was hoped that would begin to level the playing field with procedure based specialists.

yet the update committee, which was tasked annually with reviewing how medicare compensates physicians for care provided, has a paltry few seats available for primary-care when accepting reimbursement rates. we want to increase the number of primary care physicians, but we disperse the same amount for a plastic surgeon as a primary care physician. if we increase hospital reimbursement for primary-care physicians in training over specialists in training, and we will have more primary care physicians. a, you could do that. i have the privilege of being a primary care physician myself. i love taking care of patients. it is one of the most fun things i do. patience invite me into their lives as i teach them to take care of themselves and get what they need. the daughter of a labor union

organizer and a social worker, i could never afford medical school. i was fortunate to be a member of the health service corps. i was free to make a decision to follow my passion and become a primary care physician, without worrying over how would pay off my loans. if medical students know before they began medical school but will have no debt, he will be more likely to pursue a career in primary care, rather than highly-, and said specialties. the administrative burden we place on positions is a product of our dysfunctional system of financing health care, with multiple private and public affairs, including hundreds of insurance plans with its own rules. the costly paperwork inflicted on our positions is enough to drive many to exit from our profession. if we would enact a single payer national health care program, where everyone was in trouble to health care as a right, we could focus on delivering the best care of the world to our patients, and relieve physicians of a ministry to passels in billing services.

the stresses on primary care physicians are tremendous. with the implementation of the electronic health record, but force them to spend more time looking at the computer than their patience. systems were designed to in hensarling, not patient care. the crate a hideous documentation burden that robs precious time from a physician that they would rather spend with their patients. if we had designed the ehr to further clinical care, we would have developed a very different tool. it is true there are elements that will preserve patients' safety. they are far overshadowed by demands for administrative documentation. will lose the narrative of the individual patient to make billing more efficient. i urge you to work to make a difference, not for me or you, but for the patients i have the privilege of serving, who desperately need elected officials to care about what happens to them. thank you.

>> thank you very much. i want to ask two brief questions in my five minutes. my understanding is, if i have the flu and a walk into an emergency room, it will cost medicaid something like 10 times more than the walking into a community health center to visit my primary health care physician. my understanding is there are millions of americans who hesitate -- i know this is true in vermont. people think they are sick and wait to get better. the wait months and months. the doctor says, why weren't you here six months ago? i have to get you to the hospital. my question is, how much money and human suffering is taking place in this country because people are unable to walk into a doctor's office when they need to? who wants to respond to that?

>> i can just tell you about the faces of the patients who line up to be seen a our walk- in clinic on a daily basis. i do not know how you measure the cost of human suffering. but we see, always -- people come to county, because you can see things you will never see anywhere else in the world, such advanced stages of disease, people with everything from and brain tumors to, breast lesions that are protruding from the skin. you say, why did you stay home? these are working folks. these are taxi drivers, college professors, accountants, attorneys. the first thing they say to me is, i never thought i would be here. i never thought i would be at the county. i would say it has to be -- no exaggeration -- millions of dollars will lose in work force productivity, as well as the

suffering. i see so many patients to get cancer, particularly breast cancer, and lose their jobs, and wind up coming to us to get further treatment. the have lost their homes, many of them, by the time the get to us. we are trying to get them started on chemotherapy and find them someplace to live. >> i know from the stories from the community health centers just in vermont -- i cannot put a dollar equation to it. we have a farm worker program that goes out to the farms and works with seasonal workers and also our farmers, who are not coming in for care. we have a 50-year-old firmer with a family history of diabetes who has never seen a doctor. actually did not know they could get a sliding fee discount because of their income. i think a lot is outreach and enrollment, understanding

cultural issues as well as being able to get them into care. >> let me switch and touch on another very important issue, in terms of how we determine reimbursement rates for physicians. and that is he the [indiscernible] it is an organization which plays an enormously important role in determining how much specialists will make and how much primary care physicians will make. apparently, we have an organization which is kind of top-heavy with people in the specialties, and weak in terms of representing primary care physicians. is this an important issue? >> a key issue -- when we talk globally about the idea of pay inequity, how do we get a handle on it? since medicare is the largest single payer, and historically many private careers key of

medicare in a variety of ways, managing the medicare conundrum around the pay gap would be central to reforming the system. at the center of it is this committee. it has been holding sway a long time. there are a variety of approaches to it. i think just sunshine, daylight. you have logging under is the question of, do you raise the floor or bring the ceiling down? both will raise all kinds of issues for people involved, philosophically and politically. i believe it is both. the point is, we are not going to a primary care physicians $500,000 a year. but i must say, when i hear about a physician making a million dollars a year, yes, there are people in business who are from their college class, a sucker i think it is a moral argument we need to engage as a country. >> i do have some additional

thoughts on this, and specifically the process by which the committee evaluates billing codes between the different sub-specialties and primary care. this process could be improved by evaluating the evaluation and management, what are called cpg codes. an ophthalmologist will build the same code for a 10 minute exam with very little followup. a primary-care physician who builds the same code generally spends 25 to 30 minutes with the patient face to face, and has 30 minutes follow-up, and an estimated 30 minutes between visits. the reimbursement for those services are identical. "we need is new codes in primary-care perry has need to update our knowledge base,

regarding this issue. current time estimates are dated to the 1980's, 25 years old, and are based on very small sample sizes. our proposal would be to review these codes in a way that is transparent, peer review, and based on real-world data. >> it determines relative values, not absolute levels, but it is a zero sum game. one could put more primary-care members on that board. i think that would be a good idea. medpac also proposed there be an outside committee, an independent committee of stakeholders, the kind of audit and review the recommendations. i do not know if that ever went anywhere, but i would encourage you to look ahead a and maybe go that way. >> thank you very much. senator? >> thank you, mr. chairman.

i'll begin by asking -- in your testimony, you describe challenges frontier states face in applying for federal grants to increase the work force. what needs to be done to improve that grant process? what can we do? >> senator, the information i receive from the community health centers refers back to the number -- when they are looking at designations, it is the number of people per provider, rather than the amount of space where those people are located in. the other thing that sometimes is a bit of a disparity is, in states like ours, where we have lower minority populations, sometimes we are put out of the running because we just do not have a high enough percentage

of minority or different types of ethnic backgrounds. then again, the wage disparity. the average statewide data states that the designated areas are financially in pretty good state, but if you were to look of the overall -- we have many people who are making a lot of money, and then some that are making very little. it skews the average. maybe look at those figures, as far as designation goes. >> thank you. as a question, what needs to be done to enhance and improve the coordination and collaboration between the federal government and state agencies to most effectively deploy the resources?

how can we avoid duplicative efforts? >> thank you. i know that at least i can speak to vermont and new hampshire, in terms of accepting not the national health service corps, loan repayment, but also a loan repayments dollar. there are restrictions on how you use those resources. the have to be within health professional shortage areas. if we could get a change from that in the federal government, states like vermont and new hampshire, who do not take any federal funding for loan repayment -- that actually would be very favorable. >> were you going to comment on that? >> i do not have enough information to be able to give you an intelligent answer, but i would be more than happy to do

some research and get back to you. >> i have questions that i how people will answer in writing. what needs to be done to make sure that effective oversight and financial controls are in place, to insure that federal funding will be used effectively, and how resources will be allocated more efficiently? >> have the rate of federal programs are quite different. i have spoken to the issue of medicare, jamming. you would not issue a contract without a deliverable, without specificity. i think oversight there is quite lax. i realize that is not the jurisdiction of this committee, but it inevitably speaks to this issue. in regard to the title seven programs, the support

educational activities, for physicians, four position assistance. they are managed fairly tightly. the use an nih grant awards system. i think there is good supervision. from the perspective of the schools, often they feel it is too tight. it is hard to move when things are highly stipulated. the national service corps is a relationship with the individuals. happily, over the years, it used to be that many individuals simply did not serve. that has been coupled with the help of federal legislation. and that is managed quite tightly. i think in this area in general, there is pretty good accountability across programs. no doubt room for improvement, but in general, it is pretty good. >> thank you. my time is expired. i have more detailed written

questions. senator warren? >> i would like to follow up with some questions about community health centers. as vehicles for delivering primary health care, and their impact on access, on costs, and on disparity. i was very interested -- i read through all of the testimony. i was very impressed by the work you have done. it is terrific work. i was glad to hear about the work that is done out in wyoming. you have community health centers there. what else do we know about this, in any of those dimensions? it is about cost. it is about access. it is about reducing disparities. your head snapped up, so i am guessing it is you. >> sorry for that. >> i like it.

>> i also worked at a community health center in idaho. my experience, they provide a critical safety net for the uninsured in our valley. the insurance rate for this population is nearly 50%, second highest in the nation. my experiences her, despite the access the clinic provides, often, how we end up providing is care that, at least in my other job, here at the v.a., we would not find acceptable, because we do not have other opportunities to offer these patients. even though the have a foot in the door, often patients are unable to access additional services that would be a standard of care in any other system in the u.s. >> thank you.

>> cook county -- >> is your microphone on? >> i thought it was. thank you. cook county pairs with many other community health centers. "we find is, when we provide access to primary care, we uncover specialty needs. one of the big problems we have as a hospital, one of our major challenges, is that these patients in the community health centers have nowhere to go to receive those services. they refer them to us. i think the community health centers are invaluable, because the offer care in the communities where people live. they are likely to be more flexible in their hours and pay scales. but then they have no where to send them. we are the safety net. it is a continuous attention we have with capacity, in meeting those needs. >> do you want to ask?

got to hit your button. >> thank you. i have worked for 20 years at the unity network, two or three miles here from here. what i saw there was a population that, were it not for the health center, would be in the emergency room. there were not private providers in the neighborhood. to the extent their work, there were not ready to do with clinical needs, language made, support needs for the population. they have hard wired in social work, mental health, and a variety of services that typified the kinds of needs that our population had. it represents, at its best, a one-stop shop. particularly attuned to the kind of population you are working with.

without that, emergency room would have been the recourse, if care was to be delivered at all. >> i would characterize it at least what we are doing in vermont -- we are working toward a redesign of the financial and delivery system. community health centers are part of that. all of them were made primary- care center. part of that is financing. you do shared savings or a global payment, or bundle payment. you are also going to change, with regard to the delivery system, in terms of mental health and specialists. you are not aligning it with regard to governance, but you are with the, medical expense. it is changing the way we do

business. it is not based on the volume of care. we are being paid on value. that system is being done at many community health centers across the nation. blackstone valley is a great example. i am sorry the senator left. the redesigned the visit to actually have the providers working at the top of their scope, bringing in more assistance to the nurses and to the health centers. they saved over a million dollars just at one help center, looking at total medical expense. in claims data, you can actually see where patients go. at the health center, you have a medical record of where they have come to see you, but do not have experience in terms of the hospital or mental health. as long as it is medical care center, it aligns the thinking of on both financing and delivery for our patients, so we think about the total medical expense, and make

interventions in primary care that matter, in terms of the outcome and finances. >> there is an estimate that we have a $24 billion savings from the current community health centers. part is coming from keeping people out of emergency rooms. part is coming from integrated care. it is a different specialist -- not specialists. different kinds of providers. it is also coming from these innovative approaches. >> a lot of the patient- centered medical home work -- in vermont, we have a blueprint, thinking about chronic care management. how you take somebody with a higher prevalence of hypertension or asthma and manage their care to keep them out of the hospital, and impatient, as well as returning to the hospital? it is about really focusing in

on the patient. >> thank you. i apologize. >> thank you, mr. chairman. thank you for the focus of this hearing. the title sort of says -- speaks volumes. 30 million new patients and 11 months ago. certainly, our state's have different experiences has removed toward that challenge, in terms of the level of uninsuredness and the distribution of providers throughout the state. i apologize earlier for having to step out, to attend another organizational meeting of one of my other committees, so i miss some of your testimony. but i've hinted that i would

like to hear a little bit more of your opinions of the level of knowledge of the impact on the non remunerative factors in increasing the supply of primary-care practitioners. i think about the anecdotal information i hear of the medical students are going through their rotations and observing the specialties, as well as joining, primary care settings. they are observing mentors and teachers with different levels of oil economy and different levels of flexibility. i think about the difference in experience one might have if they are in a setting where they are modeling a patient- centered medical home. other savings would be for service or traditional payment

systems. how much is their mentor or teacher on call? every night? is it more reasonable. i wonder how these compensatory factors play into the decision to specialize or to go into primary care, and students have these observations and are looking at the future of how we design medicare. >> medical schools and teaching hospitals, over the years, for good reasons, have developed a sub-specialty oriented culture. all of our medical medical

schools have that element. some do better in local focus. i would like to see every medical school have a workforce plan. i travel often to medical schools and say, what is your geography? state schools do a little better. they say, "our state," but it could be better. illinois would be an example of a new model of changing the culture. an osteopathic medical school in phoenix now do one year on campus for the basic sciences. they distribute them to one of 11 community health centers. they do all their teaching and all of their clinical medicine working with local or regional hospitals. that is really breaking the mold. there are other experiments under way. we have 10 of our leading

universities that do not even have a family practice departments, that are saying and that is core to the health of this country, and the nature of the physicians. there is probably a great deal that could be done. that is just a sample of possibilities. >> i do not know if other of our witnesses would like to comment on this. how much do we know about this, rather than the anecdotal sharing we here? >> the massey foundation, in 2009 or even later, has published a really comprehensive report on this issue, on the whole workforce issue, he and lifted these non- financial for actors.

inner-city people who demonstrate they are interested in this -- through the admissions process, you could probably rearrange the classes. there is no guarantee, but nevertheless, you could go there. a part of it is the culture. i have read about that also. one of the senators mentioned and that in primary care. one way perhaps to do this is through, a graduate education support. most economists do not think it is warranted, that these residents are cheap labor to a hospital. but you could differentiate and give a teaching hospital more if they develop programs that specifically acculturate students into this, so that the

presidency is in community centers, and they have first- rate faculty who mentor them. i think medical schools react very much like everyone else to the money. i think through medical education, without asking much in return. >> thank you, senator baldwin. senator murphy? >> thank you very much, mr. chairman. i worry a little bit about our ability to micromanage this problem. i think a lot of the ideas we are talking about are incredibly important. whether it is rate setting or loan forgiveness programs, i am sometimes more attracted to ideas that reset the marketplace itself, to give the

marketplace more reason to invest in primary care. one of the themes we talked about is what this new delivery system that is potentially based on bigger systems of care, accountable care organizations, more physicians working for salary rather than fee-for- service -- it may help solve this procedure issue. if you are in charge of specialists instead of just referring out to specialists, you feel a little bit better about your work. there is probably also a theory that says that if you have more primary-care doctors working for organizations, rather than working on their own, and you are getting a big bundle payment to take care of a big group of patients, he are going to be incentivized to pay a primary care physicians more, because that will help them manage their costs and help keep the delta of whatever they save.

you already see that happening. you see more primary-care physicians going to work for hospitals in connecticut. the are buying a primary care groups and working for salary. is there a potential that, as you shift a delivery system to have more integrated systems of care, more accountable care organizations, he that there will be an incentive for the organization's to pay primary- care doctors more, separate from decisions we may make on reimbursement? maybe i will put this to the economist first. dr. reinhardt, what do you think ultimately the shift in delivery system may mean for the kind of rates that primary care of doctors get paid? >> the great hope is that it will do exactly that, that bundled payments -- ideally,

there should be bundled payments for care. somebody is in charge of managing the money from that bundle. having a heavy component of primary-care is costs- minimizing and profitable in that way. i once talked to a group, north texas medical group. there were an integrated ipa who took risks. the hospital piece was done by pacific health care. they did the medical peace. they may have already who tilted the schedule already of primary care substantially, and paid the specialists less. they were at risk. it might be worth talking to them. they were one of the first pioneer aco's. it might be interesting to invite them to tell you what

they experienced. >> you have expressed skepticism, based on the cost savings that medical home models may provide what we know about the ability for aco's with primary-care doctors elevated to get cost savings that maybe we have not seen in some of the early rollouts of medical home models? >> to my knowledge, we know very little about how aco's will reduce costs, or what their effect on costs will be. "we could look to is the model of care where i practice, which is in the va, which is the ultimate integrated care model. we have people for life after their return from service, and do a good job taking care of them. i understand that we provide care that is of similar or better quality to most private

institutions in the united states at costs that are much lower. >> you have a provocative statement about the interests the ama may be serving. can you elaborate on that? >> i am happy to. my personal position on this is that this subcommittee of the ama wields inordinate power over physician rate setting. i know we are trying to get away from remuneration, but the federal government is sending a clear price signal to students about what the federal government would like them to practice in. i think to minimize that is a little bit dangerous. my personal view is that physician groups treat public affairs as though they were their own income programs, rather than a source for the u.s. population. >> thank you, senator murphy. senator?

>> thank you. i have two questions. one would be more specific, and the second is more broad base for the whole panel. but we appreciate your testimony here today. the specific question -- maybe i will direct it to dr. mullen, or dr. fagan, or anyone in between who wants to comment on this. it relates to health care as it relates to children. our child advocates always remind us that in the context of health care and otherwise, children are not small adults. they are different. we have to treat them differently and have strategies that recognize the reality. when we were going through the june-july, or may-july debate about health care in this committee. senator dodd and i worked together to design elements in the bill that would speak directly to the reality. we have one in particular that

spoke to the work force, section 5203, establishing a loan repayment program for pediatrics of specialists. -- sub-specialists, and providers of mental health care working in shortage areas. that was our intent. we were successful in that. i am wondering, now that we are beyond the theoretical stage, and we have a piece of legislation which is in place, and continuing to be implemented, in this broader topic of primary care, further steps we need to take to make sure that the primary care physician and the services and treatments that come with it are available for children? a doctor, i do not know if you have a thought about that. >> a thank you.

your observations about children are of course on point. children are more vulnerable. they are poorer. they are more underserved and the rest of the population, as a matter of analysis of the benefits that come to children. we are definitely weighted toward the elderly in terms of public benefits. that creates a challenge, particularly with principles of trying to be inclusive and bring kids in. i think we are optimistic with the medicaid expansion, where it occurs, kids will get better benefits than i have in the past. specific issues in pediatrics -- generally, the notion of primary care does not include sub-specialties. i think probably the correct motion is underserved or underpopulated disciplines, which primary care is at the heart of, but there are others. for instance, we could have a growing shortage in pediatric sub-specialties.

i do not know the arguments well, but they have been pretty well substantiated. there is not a tendency of pediatricians to specialize. there are not enough training programs. we probably need more. the spirit of the legislation makes sense, in terms of work force development. i would not want to see the profile -- well over 2/3 of adult internists are specializing and going into hospital medicine, which is a good development, but takes them out of primary care. there is that challenge. by and large, pediatrics has had a good market. medical students like it. they tend to go into it in good numbers. pediatrics is not short. it takes some out of the primary health care field. >> your vantage point from chicago? >> pediatrics has had a good

market. medical students like it. pediatrics overall is not short. the number of specialists available and general hospitals is low. in chicago, we have a glut of the-hospitals. the specialists are generally available a lot but in the more rural communities, this is a tremendous challenge preventing -- providing access to children needing multi discipline support. encouraging people not only to produce specialties data are poorly distributed in the areas of need. >> i will hold my second question. anyone in the 15 seconds we have? i will put a question in the record because we are out of time. thank you.

>> let me conclude by thanking all of these senators who have participated in this hearing. the large turnout tells you how seriously many of us feel about this issue. most importantly, i want to thank our panelists for their testimonies. we are going to listen very seriously to what you had to tell us. i especially want to thank those who came from such far distances. thank you all very much for your help. this hearing is adjourned. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2013]

>> next, "q&a" with a political columnist. unlike at 7:00 a.m., your calls and comments on "washington journal." -- at 7:00 a.m., your calls and comments on "washington journal ." here's a look at some new members of the 113th congress. there are two new freshman from california. ami bera is a medical doctor who defeated ban lungren in a newly redrawn district near sacramento. david valadao is a managing partner at a dairy farm which he owns with his brother. watch the house lights on c-span and the senate on c-span2. >> congress is back today. the house is in at 2:00 eastern to take up a small number of bills under suspension of rules

with votes at 6:30. the house plans to vote and debate on a measure to require the president to submit a balanced budget to congress. the senate also in at 2:00 eastern for general speeches. at about 5:30, they will vote on the motion to proceed on the violence against women act. both members -- both parties are attending retreats this week. the senate will be out tuesday and wednesday. the legislative business in the house on thursday or friday. live coverage of the house on c- span and senate on c-span2. >> if you have of hot shot that just got her ph.d. in computer science from stanford, she is getting offers from all over the world. to say that you can stay in some limbo for six years, it is not really competitive. >> yes, government, congress can do a lot, and you do not have to be efficient on your iphone or

blackberry to understand the application of technology and what makes it work and what doesn't make it work. >> is very difficult to make investment decisions and expect any kind of return on investment and have no way to predict the future. our difficulty right now is that there is no consistency or certainty in our policy decisions. >> of the government's role in technology and policy from this technology show. >> this week on "q&a" -- mark shields discusses his early career in politics and his transition to journalism. >> mark shields -- can you remember the first time you did work in front of an audience